AAAPT Diagnostic Criteria for Acute Thoracic Surgery Pain

Practice Advisory for Postoperative Pain Management of Thoracic Surgical Patients: A Report from the Society of Cardiovascular Anesthesiologists

Pain after thoracic surgery is often significant, which can disrupt normal respiratory mechanics and impair the clearance of secretions, thus increasing the risk of postoperative respiratory complications. Poorly controlled acute pain can lead to persistent post-thoracotomy pain and continued opioid use that can affect quality of life. With the increased awareness of opioid-associated adverse effects and recent emphasis on enhanced recovery, opioid-sparing multimodal analgesia has been used widely for acute pain management after thoracic surgery. This practice advisory reviews, evaluates, and summarizes the recent literature related to pharmacological therapies and non-pharmacological therapies used for postoperative pain management after thoracic surgery and offers guidance to providers in making appropriate pain management decisions for their patients.

The Efficacy of Liposomal Bupivacaine in Thoracic Surgery: A Systematic Review and Meta-Analysis

Purpose

Patients undergoing thoracic surgery suffer from severe postoperative pain, and a series of complications will occur if there is no effective analgesic treatment. Liposomal bupivacaine (LB) is a novel multivesicular formulation with up to 72 hours of analgesia, which can be used in thoracic surgery. This meta-analysis aimed to evaluate the efficacy of LB in improving recovery in patients undergoing thoracic surgery compared with non-liposomal local anesthetics.

Patients and Methods

A literature search was conducted using PubMed, Cochrane Library, Embase, and Web of science, and to identify all observational or retrospective studies and randomized controlled trials (RCTs) from inception to December 2023. The primary outcome was the in-hospital postsurgical opioid consumption in morphine milligram equivalents (MMEs). Secondary outcomes included 24-hour postoperative MMEs, postoperative pain score in the first 24 and 48 hours, hospital length of stay (LOS), time to first ambulation, readmission, and perioperative complications. RevMan 5.3 was used for the data analysis.

Results

A total of 10 studies were included in the analysis, of which eight were observational or retrospective analyses and two were RCTs. There were no significant differences in the postoperative MMEs, pain score, LOS, time to first ambulation, readmission, and perioperative complications.

Conclusion

According to this meta-analysis, LB was found to be not superior to non-liposomal local anesthetics for analgesic and functional outcomes in thoracic surgery.

Peri-operative approach to esophagectomy: a narrative review from the anesthesiological standpoint

Objective

This review summarizes the peri-operative anesthesiological approaches to esophagectomy considering the best up-to-date, evidence-based medicine, discussed from the anesthesiologist’s standpoint.

Background

Esophagectomy is the only curative therapy for esophageal cancer. Despite the many advancements made in the surgical treatment of this tumour, esophagectomy still carries a morbidity rate reaching 60%. Patients undergoing esophagectomy should be referred to high volume centres where they can receive a multidisciplinary approach to treatment, associated with better outcomes. The anesthesiologist is the key figure who should guide the peri-operative phase, from diagnosis through to post-surgery rehabilitation. We performed an updated narrative review devoted to the study of anesthesia management for esophagectomy in cancer patients.

Methods

We searched MEDLINE, Scopus and Google Scholar databases from inception to May 2021. We used the following terms: “esophagectomy”, “esophagectomy AND pre-operative evaluation”, “esophagectomy AND protective lung ventilation”, “esophagectomy AND hemodynamic monitoring” and “esophagectomy AND analgesia”. We considered only articles with abstract written in English and available to the reader. We excluded single case-reports.

Conclusions

Pre-operative anesthesiological evaluation is mandatory in order to stratify and optimize any medical condition. During surgery, protective ventilation and judicious fluid management are the cornerstones of intraoperative “protective anesthesia”. Post-operative care should be provided by an intensive care unit or high-dependency unit depending on the patient’s condition, the type of surgery endured and the availability of local resources. The provision of adequate post-operative analgesia favours early mobilization and rapid recovery. Anesthesiologist has an important role during the peri-operative care for esophagectomy. However, there are still some topics that need to be further studied to improve the outcome of these patients.